Trend in mortality from mental and behavioral disorders due to alcohol use in Brazil, 2010-2021

Abstract Objective: To analyze the trend in mortality from mental and behavioral disorders due to alcohol use in Brazil, 2010-2021. Methods: This was an time series study using Mortality Information System data. Annual percentage change (APC) and 95% confidence intervals (95% CI) were calculated using Prais-Winsten linear regression. Results: Mortality showed a stationary trend for Brazil as a whole (APC = 0.6; 95%CI -4.2;3.0), a falling trend in individuals aged 20-29 years in the South (APC = -7.4; 95%CI -10.0;-4.3) and Northeast (APC = -3.4; 95%CI -6.4;-0.4) regions, in people aged 30-39 in the Midwest region (APC = -3,8; 95%CI -7.4;-0.1) and 40-49 in the South (APC = -2.1; 95%CI -3.8;-0.4), North (APC = -3.1; 95%CI -5.7;-0.5) and Midwest (APC = -2.9; 95%CI -5.5;-0.3) regions. Conclusion: Mortality from mental and behavioral disorders due to alcohol use showed a stationary trend nationally and a falling trend in some age groups regionally.


INTRODUCTION
Alcohol is a legalized and widely disseminated psychoactive drug, which acts directly on the central nervous system causing chemical and physical dependence. 1 Harmful use of this substance is a public health problem, causing illness, disability and death, and is associated with the appearance of more than 200 diseases and health problems, including mental and behavioral disorders and infectious diseases, such as tuberculosis and HIV.Furthermore, it causes unintentional and intentional injuries, such as those caused by traff ic accidents, violence and suicide, resulting in social and economic problems for individuals and society in general. 2 Every year worldwide, approximately 3 million deaths are due to harmful use of alcohol, accounting for 5.3% of total deaths.Based on calculations of disability-adjusted life years lost, 5.1% of the global burden of disease and injury is attributed to alcohol consumption.With regard to Brazil, where around 6.2% of deaths are related to alcoholic beverage consumption, alcohol ranks third nationally and fourth globally among risk factors for disease burden. 3ntal and behavioral disorders associated with excessive alcohol consumption contribute to continuing morbidity and mortality and disabilities resulting from its harmful use, 3,4 in particular acute intoxication, use that is harmful to health, dependence syndrome, withdrawal syndrome, withdrawal syndrome with delirium or acute confusional state, alcohol-induced psychosis, amnestic disorder, residual or lateonset psychotic disorder, other mental or behavioral disorders and unspecified mental or behavioral disorder. 57][8] However, mortality due to mental and behavioral disorders is an underexplored topic, lacking studies that assess it among Brazilian adults, these being the main excessive consumers of alcohol in Brazil.
The objective of this study was to analyze the trend in mortality from mental and behavioral disorders due to use of alcohol in Brazil, from 2010 to 2021.

Design
This was an time series study, aimed at analyzing the trend in mortality due to mental and behavioral disorders resulting from alcohol use in Brazil, from 2010 to 2021.The units of analysis were the f ive Brazilian geographic macro-regions: North, Northeast, Southeast, South and Midwest. 4

Background
Brazil, the largest country in Latin America and f ifth largest in the world in terms of

Main results
The mortality coefficient was highest in the 50-59 year age group.Mortality showed a stationary trend in Brazil as a whole, falling in individuals aged 20-29 (South; Northeast), 30-39 (Midwest) and 40-49 (North; Midwest; South).

Implications for services
Mental and behavioral disorders due to alcohol use affect Brazilians at different stages of life, and it is essential to raise the population's awareness as to reducing consumption of alcoholic beverages.

Perspectives
The need exists to target actions to promote health and prevent mortality related to alcohol use, with emphasis on the 50-59 age group.territorial area, had a population of 203 million inhabitants in August 2022, distributed over 5,571 municipalities in 26 states and the Federal District.

Participants
This was study of deaths of adults aged 20 to 59 whose underlying cause of death was "mental and behavioral disorders due to use of alcohol", occurring in Brazil between 2010 and 2021.

Variables
The variables used in this study were:

Data sources and measurement
The mortality data were extracted f rom the Mortality Information System (Sistema In order to calculate coefficients of mortality f rom mental and behavioral disorders due to use of alcohol, we divided the number of deaths according to place of residence (numerator), in the period studied, by the population in the same period and place of residence (denominator), and then multiplied the quotient by 100,000 inhabitants.These coefficients were calculated by age group, sex, race/skin color and geographic macro-region of Brazil, for each year of death.The arithmetic mean was then calculated, adding together the coefficients for each year and dividing them by the total of 12 years studied.For the purposes of controlling aggregation bias, data on the population studied were stratified by macroregion, sex, age group and race/skin color, so as to achieve better characterization of mortality through a more homogeneous comparison of the population.

Statistical methods
The data were grouped into spreadsheets on the Microsoft Excel platform and exported to the Statistical Package for the Social Sciences (SPSS), version 2.0, which we used to perform statistical analyses.We used the Prais-Winsten linear regression model to verify temporal trend, as it is the recommended method for correcting serial autocorrelation and enabling analysis of time series of study periods greater than nine years. 9The mortality rate for mental and behavioral disorders due to use of alcohol was taken as the dependent variable (Y), according to age group, sex, race/skin color and geographic macro-region; while the independent variable (X) was the year of death, between 2010 and 2021.M o r t a l i t y c o e f f i c i e n t t r e n d s w e r e interpreted as follows: rising trend when APC was signif icantly positive; falling trend when APC was signif icantly negative; and stationary trend when there was no significant difference between the APC value and zero. 6

Ethical aspects
This study used secondary data available f rom off icial Brazilian Ministry of Health, databases whereby study participants were not identif ied.Therefore, submission to a Research Ethics Committee was not necessary, in accordance with National Health Council Resolution No. 466, dated December 12, 2012.

RESULTS
Between 2010 and 2021, Brazil recorded 60,513 deaths f rom mental and behavioral disorders due to use of alcohol.The Southeast region of the country recorded the highest number of deaths due to this condition (22,910), while the Northern region (2,056) recorded the lowest number of deaths.
The majority of deaths corresponded to individuals of the male sex (90.0%), with the highest proportion of individuals in the 50-59 age group (40.6%) and of self-reported mixed race (50.3%) (Table 1).
The mortality coeffcient was higher in the 50-59 age group, both for Brazil as a whole and also for each of the country's macro-regions.In Brazil as a whole, the mortality coefficient for the 50-59 age group ranged from 10.1 to 11.3 per 100,000 inhab.between 2010 and 2021, indicative of a stationary trend (APC = 0.5; 95%CI -3.1;4.2).The other age groups showed a reduction in the coeff icient, both for the entire country and also for each of its regions (Figure 1).

DISCUSSION
This study identified a stationary trend in the number of deaths from mental and behavioral disorders due to use of alcohol, for Brazil as a whole.The male population accounted for the majority of deaths, the highest proportion among age groups corresponding to those aged 50-59, and more than half of the total selfreported themselves as being of mixed race/ skin color.Analysis by region showed a falling trend in individuals aged 20-29 (Northeast and South), 30-39 (Midwest) and 40-49 (North, South and Midwest).
Deaths resulting from mental and behavioral disorders caused by use of alcohol are a constitute condition faced worldwide.Taking Brazil as a reference, between 2010 and 2021, there were more deaths f rom this disease than f rom tuberculosis, mainly among people of the male sex, aged 50-59 and of mixed race/skin color.
Predominance of deaths among men has also been found in other studies.The male sex is also related to a higher frequency of hospitalizations resulting from abusive consumption of alcoholic beverages, 4,6 a possible reflection of the greater and more frequent habit of alcoholic beverage consumption among men.Men start drinking at an earlier age, while there is social and cultural repression for women to not drink excessively.However, a signif icant increase in the consumption of this substance among women has been seen in recent years. 2 In our study, deaths were concentrated among Black people (people of Black and mixed race/skin color).This finding corroborates data from another study, which investigated the distribution of deaths attributable to alcohol in Brazil and revealed that 60.0% of them occurred among people of Black and mixed race/skin color. 6Another study that analyzed abusive alcohol consumption, based on National Health Survey data, also showed a higher prevalence of consumption among people of Black race/skin color. 2 These race/skin color indicator results point to an influential factor regarding the poorer health condition of Black people, compared to White people.Historically, the Black population has been more vulnerable to conditions of social and economic inequality, exposed to an overload of risk factors, such as excessive alcohol consumption, sometimes cited as an "escape valve" for these difficulties, which can increase the risk of susceptibility to diseases and harm caused by alcohol abuse. 11 for age group, in three regions of Brazil, individuals aged 50-59 were those who died most as a result of mental and behavioral disorders due to use of alcohol.According to overall mortality data from the 2015 "Saúde Brasil" health survey, there was a tendency for mortality coeffcients to increase in this age group, 11 which could directly affect the country's economy: this is an age at which people generally are still economically active.On this point, it is worth noting that in 2021 life expectancy at birth in Brazil was 77 years. 6e average age for first alcohol intake in Brazil is 12.5 years.The earlier such consumption begins, the greater the likelihood of developing harmful patterns, such as dependence. 12,7,13hen uncontrolled, excessive alcohol intake can contribute to the emergence of comorbidities in the long term and, consequently, death in later life.
In Brazil, the trend of deaths from to mental and behavioral disorders due to use of alcohol varied between age groups, especially in the 20-29 year group, and also between the country's macro-regions.The decrease in the number of deaths among people aged 20-29 has continued to occur over the last 20 years in Brazil.Between 2000 and 2013, this age group accounted for only 3.9% of deaths with underlying and/or associated causes fully attributable to alcohol use. 8There was also a 4.0% reduction in alcohol consumption among people in the 20-29 age group between 2013 2019, when comparing the rates for these years. 6From 2010 to 2020, the rate of mental and behavioral disorder hospitalizations due to alcohol use by individuals aged 20-29 was also low, in comparison with such hospitalizations in the other age groups analyzed. 5ch results can be attributed to a combination of factors, such as (i) younger people seeking to have a healthier lifestyle, (ii) affirmation of individual identities, (iii) concern about the future and (iv) social pressures. 14rthermore, it is important to highlight that, among the four regions of the country that showed a falling trend in deaths from mental and behavioral disorders due to use of alcohol, the Midwest and Southern regions showed a falling trend for two different groups.
Similarly to this finding, studies that analyzed mortality due to alcohol dependence and spatial distribution of deaths attributable to use of this substance 4,6 in the Brazilian population showed that the Southern region of Brazil had the lowest mortality rate in relation to the other regions of the country.Between 2010 and 2020 the Midwest region showed a falling trend in hospitalization rates for mental and behavioral disorders due to use of alcohol. 5e falling trend seen in these regions may be related to legislation and strategies to prevent and reduce harm from alcoholic beverages and other drugs in Brazil, such as the prohibition of the sale of alcoholic beverages to minors under 18 years of age, as per article 243 of the Child and Adolescent Statute (Law No. 8069/1990) and by article 63 of the Criminal Misdemeanors Law; and by Law No. 11705/2008, known as the Dry Law.These laws have had a positive impact on the number of hospitalizations resulting from alcohol consumption, contributing to a reduction in the mortality rate due to alcoholrelated disorders. 15 is noteworthy that the Southeast and Northeast regions, despite having shown a stationary trend in mortality from mental and behavioral disorders due to use of alcohol, were the regions with most records of this condition.
Regarding the limitations of this research, the quality of the Mortality Information System stands out, given the possibility of underrecording of deaths, problems of duplicity and reliability of Death Certificate information, widely reported in the literature, 16 which may also underestimate mortality from mental and behavioral disorders due to use of alcohol, thus compromising interpretation of trends found.However, these limitations did not invalidate the findings of this study in terms of informing public policy implementation, with emphasis on geographically specific actions, prioritizing territories where high mortality rates due to alcohol use were found.
We conclude that, although the mortality trend has remained stationary in Brazil, it presents variations in its distribution across the country's major geographic regions, especially with regard to age group.We recommend that further studies be carried out that take into account other variables, such as education, occupation and family income, paving the way for proposition of new explanatory hypotheses for the trend found in the mortality rate from mental and behavioral disorders due to use of alcohol in Brazil.
20-59 years old, Brazil, 2010-2021 Table 2 -Trends in coefficients of mortality from mental and behavioral disorders due to use of alcohol in individuals 20-59 years old, by geographic macro-region and sex, Brazil, 2010-2021 a) APC: Annual percentage change; b) 95%CI: 95% confidence interval; c) p-value: Significance of coeffcient association using Prais-Winsten t test regression analysis; d) Stationary trend when p-value ≥ 0.05.

Figure 1 -
Figure 1 -Coefficients of mortality from mental and behavioral disorders due to use of alcohol in individuals 20-59 years old, by national macro-regions, Brazil, 2010-2021

Table 3 -Trends in coefficients of mortality from mental and behavioral disorders due to use of alcohol in individuals 20-59 years old, by region and age group, Brazil, 2010-2021
Transtornos Relacionados ao Uso de Álcool; Mortalidade; Alcoolismo; Estudos de Séries Temporais; Saúde do Adulto; Saúde Mental.